State Firearm Laws and Nonfatal Firearm Injury-Related Inpatient Hospitalizations

INTRODUCTION:Existing evidence on clinical and economic effectiveness of one long-acting injectable antipsychotic (LAI) versus another in successful management of schizophrenia is scarce. The study was conducted to compare all-cause inpatient healthcare utilization and associated costs among Medicaid patients with schizophrenia who initiated LAIs.METHODS:This retrospective cohort analysis used the Truven Health Analytics MarketScan® Medicaid claims database. Schizophrenia patients >18 years with at least one claim for one of the following LAI were identified between 1 January 2013 and 30 June 2014 (identification period): aripiprazole, fluphenazine, haloperidol, paliperidone palmitate, and risperidone. The first day of initiating an LAI was considered the index date. Patients were followed for 1 year from index date. Logistic and general linear regression models were used to estimate risk of inpatient hospitalization and associated costs during follow up.RESULTS:Of the identified Medicaid patients with schizophrenia, 1,672 (36.7 percent) initiated an LAI: 44.0 percent received paliperidone, 26.4 percent haloperidol, 13.8 percent risperidone, 9.2 percent aripiprazole, and 6.6 percent fluphenazine. With the aripiprazole cohort as the reference group, the odds of having any inpatient hospitalizations were significantly higher in haloperidol [Odds Ratio, OR (95 percent Confidence Interval, CI): 1.51 (1.05 - 2.16)] and risperidone [OR (95 percent CI): 1.58 (1.07 - 2.33)] cohorts. Fluphenazine and paliperidone palmitate cohorts also had higher risk of having any inpatient hospitalizations compared with aripiprazole, but the differences were not statistically significant (p>.05). Among LAI initiators with any inpatient hospitalizations, the adjusted mean inpatient costs were lowest in the aripiprazole cohort (USD25,616), followed by haloperidol (USD30,811), paliperidone (USD30,833), risperidone (USD31,584), and fluphenazine (USD37,338), although differences were not statistically significant.CONCLUSIONS:Our study findings highlight the value of aripiprazole in reducing inpatient hospitalizations and associated costs among patients with schizophrenia. However, our study is limited as our results are reflective of a multi-state Medicaid population. Future studies are warranted to confirm the results in non-Medicaid patient populations.

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The “Rules of the Road”: Ethics, Firearms, and the Physician's “Lane”

The Journal of Law Medicine & Ethics ◽

10.1177/1073110520979415 ◽

2020 ◽

Vol 48 (S4) ◽

pp. 142-145

Author(s):

Blake N. Shultz ◽

Benjamin Tolchin ◽

Katherine L. Kraschel

Keyword(s):

Medical Ethics ◽

Patient Autonomy ◽

Critical Role ◽

Firearm Injury ◽

Agency Relationship ◽

The Road ◽

Firearm Violence ◽

Patient Agency ◽

Foundational Principle ◽

Do So

Physicians play a critical role in preventing and treating firearm injury, although the scope of that role remains contentious and lacks systematic definition. This piece aims to utilize the fundamental principles of medical ethics to present a framework for physician involvement in firearm violence. Physicians' agency relationship with their patients creates ethical obligations grounded on three principles of medical ethics — patient autonomy, beneficence, and nonmaleficence. Taken together, they suggest that physicians ought to engage in clinical screening and treatment related to firearm violence. The principle of beneficence also applies more generally, but more weakly, to relations between physicians and society, creating nonobligatory moral ideals. Balanced against physicians' primary obligations to patient agency relationships, general beneficence suggests that physicians may engage in public advocacy to address gun violence, although they are not ethically obligated to do so. A fourth foundational principle — justice — requires that clinicians attempt to ensure that the benefits and burdens of healthcare are distributed fairly.

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Abstract 6: What Proportion of High-Cost Patients’ Inpatient Spending is Preventable?

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.6.suppl_1.a6 ◽

2013 ◽

Vol 6 (suppl_1) ◽

Author(s):

Karen E Joynt ◽

Atul Gawande ◽

E. John Orav ◽

Ashish K Jha

Keyword(s):

Outpatient Care ◽

Hospital Costs ◽

Outpatient Service ◽

Acute Care Hospital ◽

Healthcare Spending ◽

Healthcare Research ◽

Care Hospital ◽

Preventable Hospitalizations ◽

Medicare Population ◽

Inpatient Hospitalizations

Objective: A small proportion of patients accounts for a substantial proportion of healthcare spending in the U.S., and the majority of costs in this group are due to inpatient hospitalizations. Many interventions targeting high-cost patients have aimed to prevent hospitalizations for common medical conditions. However, there is surprisingly little data on the proportion of inpatient hospitalizations among high-cost patients that are potentially preventable. We sought to determine the proportion and dollar value of preventable hospitalizations among the high-cost Medicare population, and if these patterns differ for non-high-cost beneficiaries. Methods: We assigned standardized costs to each inpatient and outpatient service contained in standard 5% Medicare files from 2009. Patients under the age of 65, those with any Medicare Advantage enrollment, and those who died during in 2009 were excluded. Costs were summed across the year and across settings for each patient in our sample. We defined those in the top decile of cost as “high-cost” patients. We then used the Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators (PQIs) to identify potentially preventable hospitalizations. These include conditions such as heart failure, diabetes, hypertension, and asthma, for which good outpatient care can potentially prevent the need for hospitalization. We calculated the proportion of short-stay acute-care hospital costs that were accounted for by these preventable hospitalizations for the high-cost and non-high-cost patient groups. All costs are projected to the total Medicare sample. Results: There were 1,710,989 patients in our sample. High-cost patients were older (median age 75 versus 73), more often male (43.2% versus 39.3%), and more often black (12% versus 9%) than non-high-cost patients, and had a higher burden of comorbid illnesses. Inpatient spending, projected to the total Medicare population, was $90.3 billion. The 10% of Medicare patients that made up the “high-cost” cohort accounted for 72% ($65 billion) of all inpatient spending. However, within the high-cost group, only 9.7% of the spending ($6.3 billion) was due to preventable hospitalizations, while the remaining 90.3% ($58.9 billion) was spent on other causes of hospitalization. Within the non-high-cost group, though their overall spending was lower, a slightly higher proportion of hospitalizations were potentially preventable (14.7%, or $3.7 billion). Conclusions: Though high-cost patients account for the majority of inpatient spending, fewer than one in ten of their hospitalizations are potentially preventable through better outpatient care. Thus, focusing on outpatient interventions such as case management may not be optimally targeted. We also need strategies that make hospital care more efficient so that each episode of inpatient care is less expensive regardless of its cause.

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